Is a difficult gallbladder worth removing in its entirety? - Outcomes of subtotal cholecystectomy.

BACKGROUND: Laparoscopic Cholecystectomy one of the commonest procedures performed worldwide isn't spared from the risks of disastrous iatrogenic complications. In patients with obscured anatomy, the idea of performing a safe total cholecystectomy can be hindered with a high risk of biliovascular injuries. In such a situation STC (subtotal cholecystectomy) comes to the rescue, where the diseased organ can be tackled fairly, without any further damage. AIMS AND OBJECTIVES: The primary aim was to look at the immediate and long-term outcomes of subtotal cholecystectomy. Subgroup analysis was done based on demographics, indications and surgical approach. MATERIALS AND METHODS: We reviewed our prospectively maintained computerized operation database over nine years. STC was defined as leaving behind any portion of gallbladder other than the cystic duct. They were subclassified as per the description given by Palanivelu. Patients were evaluated with laboratory and radiological assessment. RESULTS: A total of 70 out of 602 patients (11.6%) underwent STC. Dense adhesion at the calot's was the most important reason for STC. Subtype B was the most common. Nine patients (12.85%) had a bile leak in the postoperative period. There were no biliary/vascular injuries and 30-day mortality was zero. 22.8% developed SSI (surgical site infection). Over a median follow up of 38 months (range 5-98), clinical examination, LFT and USG revealed no abnormality in any of the patients. CONCLUSION: Subtotal cholecystectomy is a useful alternative during difficult gallbladder surgery. It should be considered early into the procedure preferably prior to conversion to an open procedure. Biliovascular injuries can be avoided and the Immediate and long-term outcomes are acceptable.

Voluntary perioperative colorectal cancer registry from Kerala-An initial overview.

BACKGROUND: Although colorectal cancer (CRC) may not be uncommon in India, accurate data regarding its demographics and surgical outcomes is sparse. METHODS: With an aim to assess demographics and perioperative outcomes of CRC in Kerala, all members of Association of Surgical Gastroenterologists of Kerala (ASGK) were invited to participate in a registry. Data of operated cases of CRC were entered on a web-based questionnaire by participating members from January 2016. Analysis of accrued data until March 2018 was performed. RESULTS: From 25 gastrointestinal surgical centers in Kerala, 15 ASGK member hospitals contributed 1018 CRC cases to the database (M:F 621:397; median age-63.5 years [15-95 years]). Rectum (39.88%) and rectosigmoid (20.33%) cancers comprised the majority of the patients. Among them, preoperative bowel preparation was given to 37.68%, minimally invasive surgery (MIS) was performed in 73%, covering stoma in 47% and had an overall leak rate of 3.58%. In colonic malignancies, MIS was performed in 56.74%, covering stoma created in 13% and had a leak rate of 2.71%. Of 406 patients with rectal cancers, neo-adjuvant radiotherapy/chemoradiotherapy was given to 51.23%. The mean hospital stay for MIS in both rectal and colonic cancer patients was significantly shorter than open approach (10.46 ± 5.08 vs. 12.26 ± 6.03 days; p = 0.001and 10.29 ± 4.58 vs. 12.46 ± 6.014 days; p = <0.001). Mortality occurred in 2.2% patients. CONCLUSION: A voluntary non-funded registry for CRC surgery was successfully created. Initial data suggest that MIS was performed in majority, which was associated with shorter hospital stay than open approach. Overall mortality and leak rate appeared to be low.

Low-tie IMA and selective D3 lymph node sampling in laparoscopic rectal resection for carcinoma rectum: comparison of surgical and oncological outcomes with the open technique.

BACKGROUND: Level of proximal lymphovascular ligation remains controversial in carcinoma rectum. High-tie inferior mesenteric artery (IMA) claims better lymph node clearance; low-tie IMA minimizes autonomic nerve injury (ANI) and ensures vascularity to anastomosis. Objective of this study is to compare postsurgical complications and oncological clearance in laparoscopic rectal resection (LRR) and open rectal resection (ORR) for carcinoma rectum, with low-tie IMA and selective D3 lymphadenectomy. METHODS: Retrospective analysis was done comparing LRR and ORR done with low-tie IMA for carcinoma rectum/rectosigmoid for significant differences (P<0.05) regarding postsurgical complications and histopathology parameters. RESULTS: A total of 118 patients; 48 in LRR group and 70 in ORR group were studied. They were comparable in age, site of lesion and clinical TNM (cTNM) stage. Comorbidities and symptoms requiring upfront surgery were more among ORR. 75% LRR and 55.3% ORR had neoadjuvant chemoradiation (NACRT). Duration of surgery was longer in LRR. Clavien-Dindo grade >3 was similar in two groups. Histopathology characteristics were also comparable; including specimen length, lymph node yield, length of distal margin and pathologic TNM (pTNM) stage. Selective D3 lymphadenectomy was done in 37.5% LRR and 37.14% ORR. And 4.16% in LRR and 4.28% in ORR were had positive IMA root lymph nodes. CONCLUSIONS: The post-surgical complications and oncological clearance of LRR done with low-tie IMA and selective D3 lymphadenectomy were found equivalent to ORR. Low-tie IMA without routine splenic flexure mobilisation had no technical issues regarding the anastomosis.

Comparison of platelet-lymphocyte ratio and CA 19-9 in differentiating benign from malignant head masses in patients with chronic pancreatitis.

INTRODUCTION: Pancreatic head ductal adenocarcinoma (PDAC) and inflammatory head masses (IHM) related to chronic pancreatitis are often difficult to differentiate. PDAC produces significant inflammatory response with resultant lymphopenia and thrombocytosis. The prognostic role of platelet-lymphocyte ratio (PLR) as a tumor marker has been defined. We aimed to find the role of PLR as a diagnostic marker for PDAC in differentiating benign head mass comparing with carbohydrate antigen 19-9 (CA 19-9). METHODS: A prospective study of patients with biopsy-proven PDAC and benign IHM with underlying chronic pancreatitis from 1st November 2014 to 30th June 2016 was performed. Total blood count including platelet count and CA 19-9 were recorded and statistically analyzed. RESULTS: There was no significant difference in total leukocyte counts (7789±2027 vs. 7568±1289 cells/mm3) between PDAC (n = 34) and IHM (n = 27). However, the mean lymphocyte (2235±837 vs. 2701±631 cells/mm3) and platelet counts in mm3 (3.36±0.789) × 105 vs. (2.45±0.598) × 105 showed difference. The median PLR was 161.9 (IQR = 117.5-205.6) in PDAC and 91 (IQR = 77.2-106.6) in IHM. The median CA 19-9 (U/mL) in PDAC and IHM was 69.3 (IQR = 22.7-427.7) and 13.9 (IQR = 7.2-23.6), respectively. On plotting the receiver operator characteristic curve (ROC curve), area under the curve was maximum for PLR (88.7%) compared to CA 19-9 (77.8%) in diagnosing PDAC (p<0.0001). Using coordinates of ROC, PLR cutoff value was 113.5 (sensitivity-79.4%, specificity-92.6%, positive predictive value (PPV)-91.5%, negative predictive value (NPV)-99.7%) while CA 19-9 cutoff value was 25.3 U/mL (sensitivity-73.5%, specificity-77.8%, PPV-78.5%, NPV-74.6%). CONCLUSION: PLR may be useful to differentiate PDAC from benign IHM in patients with chronic pancreatitis.

Evaluation of Gold's nomogram for predicting recurrence-free survival in gastrointestinal stromal tumors in Indian patients.

Gold described a nomogram for prediction of recurrence-free survival (RFS) after surgery for gastrointestinal stromal tumors (GIST). This retrospective study was intended to evaluate the utility of this nomogram for predicting a 2-year RFS in our patients. Twenty-eight consecutive eligible patients from January 2009 to January 2013 who underwent R0 resection and had histopathologically proven GIST were included in the study. Nomogram predicted RFS was compared with observed RFS in four groups as in the National Institutes of Health (NIH)-Fletcher classification. Calibration was assessed by plotting the predicted probabilities of RFS against the actual outcome. For validation of the nomogram, the graph obtained should be closer to the 45-degree line. The observed overall 2-year RFS was 85.7 % (24 patients). Four patients had recurrence within 2 years. The observed RFS was 87.5 %, 77.8 %, 90 %, and 100 % in the high, intermediate, low, and very low risk groups, respectively. The nomogram predicted the 2-year RFS was 40 %, 84.8 %, 88.6 %, and 90 % for high, intermediate, low, and very low risk groups, respectively. Thus, the predicted probabilities of the 2-year RFS in intermediate, low, and very low risk groups were similar to the observed outcomes. However, for the high risk group, the observed RFS was better than predicted RFS. This variation in the high risk group may be due to the use of adjuvant imatinib in our study.

Clinical profile of PanIN lesions in tropical chronic pancreatitis.

BACKGROUND: Chronic pancreatitis (CP) found in the tropical countries is known to have a higher risk for carcinoma of the pancreas. This study aimed to explore the clinical profile of pancreatic intraepithelial neoplasia (PanIN), one of the precursors of carcinoma of the pancreas, in tropical CP and to identify the possible clinical predictors of the same. METHODOLOGY: A retrospective study was done enrolling patients who underwent either Frey's procedure or pancreatic resection for symptomatic CP, between January 2008 and December 2012. They were grouped into PanIN positive and PanIN negative based on histopathology. Their clinical and laboratory parameters were compared statistically to identify the predictors of the PanIN status. RESULTS: Sixty-two tropical CP patients who had Frey's procedure or pancreatic resection were enrolled into this study; 38.7 % cases showed PanIN changes and 61.29 % had no PanIN changes. Majority of the clinical and laboratory parameters were found comparable between the two groups except obstructive jaundice and CA 19-9 value >137.5 which were there in 54.2 % of PanIN-positive cases. On histopathology, 54.83 % cases were benign CP and 45.16 % were malignant CP. Among the benign CP, 33.3 % were PanIN positive and among those with malignancy 66.7 % were PanIN positive. Low-grade PanINs were seen in 73 % cases of benign CP and in 26.1 % of malignancy whereas high-grade PanIN-3 lesions were seen exclusively in patients with malignancy. CONCLUSION: High-grade PanIN-3 lesions showed significant association with pancreatic malignancy. Obstructive jaundice and CA 19-9 ≥ 137.5 could predict PanIN positivity.

Scanning electron microscopic analysis of pancreatic tissue in alcoholic and tropical chronic pancreatitis.

INTRODUCTION: Chronic Pancreatitis (CP) is a heterogenous disease with alcoholic chronic pancreatitis (ACP) dominating in the West, and idiopathic or tropical chronic pancreatitis (TCP) in the tropics. The aim of this study is to assess the feasibility of using a scanning electron microscope (SEM) to analyze the ultra-structural changes in alcoholic and tropical subtypes of CP. METHODS: Chronic pancreatitis tissue samples were taken from the biopsy samples of 16 patients (seven ACP and nine TCP) who underwent drainage procedures for CP. These samples were subjected to SEM analysis and findings of normal pancreas were compared with those of CP for appreciating differences in their architectural changes. RESULTS: Normal architecture of pancreas could be observed as lobules of parenchyma, ductal system and definite loci of Islets of Langerhans (IOL). CP samples showed loss of architecture in the form of severe fibrosis and calcifications. In ACP, the fibrosis was predominantly seen towards the periphery of the gland sparing the periductal areas. These fibres were strangulating and damaging the parenchyma. Crystals were seen over these fibres. In TCP, fibrosis was moderate and uniform throughout the parenchyma. Moreover the crystals were larger and intraluminal. Total fatty replacement of parenchyma was a striking feature in TCP, seen exclusively in diabetics with gross atrophy of IOL. CONCLUSION: SEM gives the real-life pictures of fibrosis, fatty change, ductal changes, calcifications and thus the actual extent of damage in CP better than the ordinary light microscopy.

MRCP Helps in Chronic Pancreatitis Complicated with Obstructive Jaundice.

When chronic pancreatitis (CP) presents with obstructive jaundice, though there is a risk for malignancy, possibility of benign biliary stricture should also be considered on treatment planning. Imaging and tumour markers have limitations in distinguishing benign and malignant lesions in CP. Here, MRI has effectively picked up a mass lesion as the cause for obstructive jaundice in CP; the patient underwent pancreaticoduodenectomy and the histopathology proved it as adenocarcinoma in CP.

Biliary tract intraductal papillary mucinous neoplasm: a brief report and review of literature.

Biliary Tract Intraductal Papillary Mucinous Neoplasm (BT-IPMN) is a very rare entity, gradually emerging into attention as sporadic cases are being reported worldwide. In this brief report we discuss about such an entity from our part of the world, based on a case from our institution. A 47-year-old female was referred to our department with jaundice, intermittent fever with chills and rigor of 6 weeks duration. Initial evaluation revealed obstructive jaundice with distended gall bladder. Imaging with ultrasonogram (USG) and magnetic resonance imaging (MRI) showed hugely dilated intra and extrahepatic biliary radicles with multiple and diffuse soft tissue lesions filling the common bile duct (CBD) extending to the ductal system of left lobe of liver. A side viewing endoscopy demonstrated mucin extruding from a prominent ampulla of Vater. The patient was managed successfully by left hepatectomy with pancreaticoduodenectomy (HPD). Gross pathological examination of the specimen showed marked dilatation of intra and extra hepatic bile ducts with multiple polypoidal lesions and plenty of mucin filling the entire biliary ductal system. Histopathology revealed predominantly intraductal papillary mucinous adenocarcinoma at the hilum extending to left bile duct with diffuse dysplastic changes throughout the biliary tree. Thus the clinical, radiological and pathological features of this lesion clearly fit into the diagnosis of BT-IPMN, which is slowly being established as a definite clinical entity with features much similar to its pancreatic counterpart.